The holiday season is synonymous with sending and receiving cards. But there’s one card many seniors won’t have in hand this holiday: a co-pay card.
Issued by pharmaceutical manufacturers, co-pay cards provide a discount for a specific medication. Many patients use co-pay cards to help afford their prescriptions. But those insured by Medicare and Medicaid are left in the cold because the federal programs don’t allow the cards’ use. The Office of Inspector General previously found the cards’ use violated federal anti-kickback laws aimed at preventing fraud and abuse.
While the law is well-intentioned, it’s problematic for people like Louis Gineris, a Chicago suburb resident who recently started needing medication to treat cardiac amyloidosis.
“I just retired three years ago, at 78, and despite having paid into Medicare for my entire career,” Mr. Gineris said, “Medicare doesn’t cover the medication I need and it prevents me from using a co-pay card that would make it more affordable.”
Gineris’ insurer requires him to pay more than $4,500 out of pocket for a three-month supply of medication to treat symptoms of amyloidosis. For now, Mr. Gineris is paying for it on his own, though not everyone can afford to do so.
“For every patient I see who is able to cover his or her share of cost, there are 10 who aren’t, maybe more,” said Dinesh Kalra, MD, a cardiologist and member of the Alliance for Patient Access.
“We’ve seen monumental diagnostic and treatment advancements in recent years, yet prohibitive out-of-pocket costs and overly strict policies are keeping many patients from realizing these benefits,” he added. “Patients who can’t afford to pay in cash and who can’t use co-pay cards are more likely to forego treatment.”
Out-of-pocket costs are often high because of health plans’ tiers structure.
Low-cost generics and even some name-brand drugs are on lower tiers. These have a flat co-pay amount, $5, $15 or even $25. But complex, targeted and cutting-edge drugs are on the highest tier, called a “specialty tier.” Instead of a co-pay, patients are charged a percentage of the drug’s cost, called co-insurance, for these medications. Patients’ co-insurance can run thousands of dollars per prescription.
Manufacturer assistance programs can help those with very low income or who lack insurance coverage; privately insured patients may use co-pay cards.
The access issues posed by federal co-pay card policy aren’t just an issue for people who have a rare disease like Mr. Gineris. Those who take medications for more common diseases such as hepatitis, cancer and arthritis could also benefit from medication discount cards too.
Medication affordability is as important now as ever as some seniors may face heightened financial insecurity because of the ongoing coronavirus pandemic. Policymakers would do well to reconsider the impact of co-pay card restrictions to ensure all patients have the support they need.